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Mauro Gargiulo
Type IA EL – Decision making, treatment, tips and tricks
Vascular Surgery
University of Bologna - DIMES
University Hospital, Policlinico S.Orsola
Bologna, Italy
Disclosure
Speaker name: Prof. Mauro Gargiulo
I have the following potential conflicts of interest to report:
X Consulting: Cook Medical
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s)
Type IA EL – Decision making, treatment, tips and tricks
Endoleak Type Origin of the leak
I Inadeguate seal at the proximal (IA) or distal (IB) end of the stent graft
II Retrograde flow from the inferior mesenteric artery, lumbar arteries, others collateral
vessels of the aneurysm sac
III Component disconnection (IIIa) or fabric disruption (IIIb)
IV Graft material porosity
V Endotension: increase of the pressure without any visible evidence of blood in the
aneurysm sac
Moll FL et al.
Eur J Vasc Endovasc Surg 2011; 41 Suppl 1: S1-S58
Conversion to open repair after endografting for AAA:A review of causes, incidence, results and surgical techniques of reconstruction
Moulakakis KD et al.
J Endovasc Ther 2010; 17: 694-702
Early Conversion Late Conversion
Incidence (mean) 0.3%-5.9% (1.5%) 0.4% - 22% (1.9%)
Mortality rate (mean) 0 – 28.5% (12.4%) 0 – 20% (10%)
Predictive factor Female gender Type I/II endoleak, graft
migration, kinking
Causes 1.Technical failure on deployment- severe iliac arteries
- inability to catheterize controlateral limb
-incorrect deployment of the stent-grafte
- insufficient connection of the variuos parts
2. Inappropriate stent graft placement- graft migration
- type I endoleak
- high deployment with renal arteries coverage
3. Vessel rupture- iliac arteries
- abdominal aorta
4. Graft thrombosis
1. Aneurysm expansion- type I/II/III endoleak
- stent-graft migration
2. Persistent endoleak
3. Endograft thrombosis
4. Graft infection
J Vasc Surg 2019;69(2):423-431
Ann Vasc Surg 2020 in press
• Proximal Aortic Cuff Extensions
• Endoanchor ± Proximal Aortic Cuff Extensions
• Primary stenting / graft balloon dilatation
• Embolization
• Chimney Technique
• F-BEVAR
Late Type IA EL - Endovascular Treatment
Vascular Surgery – University of Bologna, Italy
•Appropriate infrarenal sealing zone to achieve a seal
– Proximal Aortic Cuff Extensions
– Endoanchor ± Proximal Aortic Cuff Extensions
– Primary stenting / graft balloon dilatation
– Embolization
• No infrarenal sealing zone
– Chimney Technique
– F-BEVAR
Vascular Surgery – University of Bologna, Italy
Late Type IA EL - Endovascular Treatment
• No infrarenal sealing zone
– Chimney Technique
• Off – the – shelf
• Treatment of choice in urgent cases
Vascular Surgery – University of Bologna, Italy
Late Type IA EL - Endovascular Treatment
• No infrarenal sealing zone
– Chimney Technique
• Off – the – shelf
• Treatment of choice in urgent cases
• TS: 93.9% (Perini et al Ann Vasc Surg 2020)
• Treatment of choice in elective cases with 1-2 chimneys configuration
Collected Transatlantic Experience from PERICLES Registry:
Use of Chimney graft to treat post-EVAR Type IA endoleaks shows good midterm resultsRonchey S et al; J Endovasc Ther 2018; 25(4):492-8
• Pts 39
• Chimney graft pacement: 1 (18-46%), multiple (21-54%)
• TS: 89.7%
• 30-day mortality: 2.6%
• Primary patency chimey grafts at 3 years: 94.3%
Late Type IA EL - Endovascular Treatment
Gutters
✓ Persistent endoleak
✓ Aneurysm diameter 90
mm
✓ Abdominal pain
85 yrs old, High risk for OR (SVS reporting standard 2017)
Vascular Surgery – University of Bologna, Italy
RA
branch
Proximal sealing
+150 mm
Alma Mater Studiorum – University of Bologna
85 yrs old, High risk for OR (SVS reporting standard 2017)
Vascular Surgery – University of Bologna, Italy
CTA @ 30-day
85 yrs old, High risk for OR (SVS reporting standard 2017)
Vascular Surgery – University of Bologna, Italy
• No infrarenal sealing zone
– F/BEVAR
• Custom-made devices
• TS: 86.2% (Perini et al Ann Vasc Surg 2020)
• Treatment of choice in elective cases
Vascular Surgery – University of Bologna, Italy
Late Type IA EL - Endovascular Treatment
Ann Vasc Surg 2016; 32:119-127.
J Vasc Surg 2018;66(6): 1676-1687
End Points Explantation F/BEVAR p
Technical Success = = .266
Cardiac complications
Renal complications
Pulmonary complications
.010
.0002
0.0002
Access-related
complications
.009
In-hospital mortality .021
30-day mortality 0.19
30-day reinterventions = = .411
J Vasc Surg 2018;66(6): 1676-1687
Type IA Endoleak– Endovascular treatment with F-BEVAR
• dislocation of iliac limb
• dislocation of iliac stent
• difficult cannulation of visceral vessels
Technical Problems
Device and Stent-graft configuration
• double reducing ties
• controlateral inverted limb
Vascular Surgery – University of Bologna, Italy
Type IA Endoleak– Endovascular treatment with F-BEVAR
• dislocation of iliac limb
• dislocation of iliac stent
• difficult cannulation of visceral vessels
Technical Problems
Device and Stent-graft configuration
• double reducing ties
• controlateral inverted limb
Vascular Surgery – University of Bologna, Italy
Type Ib endoleak
Dislocation of iliac limb by F-B/EVAR introduction
Vascular Surgery – University of Bologna, Italy
• dislocation of iliac limb
• dislocation of iliac stent
• difficult cannulation of visceral vessels
Type IA Endoleak– Endovascular treatment with F-BEVAR
Technical Problems
Device and Stent-graft configuration
• double reducing ties
• controlateral inverted limb
Vascular Surgery – University of Bologna, Italy
Dislocation of iliac leg stent by F-B/EVAR introduction
Vascular Surgery – University of Bologna, Italy
Vascular Surgery – University of Bologna, Italy
Genesis
FB-EVAR
Vascular Surgery – University of Bologna, Italy
Vascular Surgery – University of Bologna, Italy
Intraoperative Angio Peri-operative CTA
Vascular Surgery – University of Bologna, Italy
Vascular Surgery – University of Bologna, Italy
• dislocation of iliac limb
• dislocation of iliac stent
• difficult cannulation of visceral vessels
Type IA Endoleak– Endovascular treatment with F-BEVAR
Technical Problems
Device and Stent-graft configuration
• double reducing ties
• controlateral inverted limb
Vascular Surgery – University of Bologna, Italy
The is a steerable
guiding sheath that offers a def ectable tip with
an ergonomic handle. The Destino™ Twist is the
ultimate tool for gaining access to the most di f cult
to reach sites, while maintaining hemostasis with
Oscor SureSeal™ technology. The Destino ™ Twist
is YOUR ONE SHEATH SOLUTION intended to
facilitate the intracardiac, renal, and peripheral
placements of diagnostic and therapeutic devices.
8.5 F
(2.80 mm)
9.5 F
(3.20 mm)
(2.20 mm) (2.50 mm)
2.20 mm 2.40 mm
6.5 F 7 F
TIP TIP
12 F
(4.00 mm)
(2.90 mm)
2.80 mm
8.5 F
TIP
Smooth tip to dilator
transition
Clear view of the distal
marker band under
f uoroscopy
Hydrophobic coated
sheath
Braided Flexsteer™
shaft technology
Tip position indicator
Rotating collar
French size and
guidewire indicator
Reliable SureSeal ™
hemostatic valve
StandardTichà Damascelli (TD) Curve
SHAFT MODELS
SHAFT DIAMETERS
9 mm 17 mm
TIP DEFLECTION
Vascular Surgery – University of Bologna, Italy
Ann Vasc Surg 2020 in press
• dislocation of iliac limb
• dislocation of iliac stent
• difficult cannulation of visceral vessels
Type IA Endoleak– Endovascular treatment with F-BEVAR
Technical Problems
Device and Stent-graft configuration
• double reducing ties
• controlateral inverted limb
Vascular Surgery – University of Bologna, Italy
Reducing Tie System
G. Oderich 2018
• dislocation of iliac limb
• dislocation of iliac stent
• difficult cannulation of visceral vessels
Type IA Endoleak– Endovascular treatment with F-BEVAR
Technical Problems
Device and Stent-graft configuration
• double reducing ties
• controlateral inverted limb (composed biforcated)
Vascular Surgery – University of Bologna, Italy
Long previous
graft
Inverted Limb
Juxtarenal and pararenal AAAs with a previous abdominal prosthesis:
Results of endovascular conversions with F/BEVAR Endograft
Vascular Surgery – University of Bologna, Italy
Conclusions
• Type IA EL happens when there is an inadequate seal at the proximal end of stent-graft
• Type IA EL is associated with an increase of sac pressure and risk of AAA rupture
• Type I A EL should be treated promptly
• Re-intervention to achieve a seal, primarily by endovascular means, is recommended
• The endovascular choice should be based on appropriate landing zone to achieve a seal
Vascular Surgery – University of Bologna, Italy
Type IA EL – Decision making, treatment, tips and tricks
Mauro Gargiulo
Type IA EL – Decision making, treatment, tips and tricks
Vascular Surgery
University of Bologna - DIMES
University Hospital, Policlinico S.Orsola
Bologna, Italy